Hospitalized Smokers: Recidivism Defined
Hospitalized Smokers: Recidivism Defined
Abstract & Commentary
By Barbara Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips reports no financial relationship to this field of study.
Synopsis: In a group of smokers who were hospitalized with cardiac symptoms, a combination of 12 weeks of behavior modification counseling plus pharmacotherapy resulted in higher tobacco abstinence rates, lower re-hospitalization rates, and markedly reduced mortality rates compared with usual care over two years of follow-up.
Source: Mohiuddin SM, et al. Intensive smoking cessation intervention reduces mortality in high risk smokers with cardiovascular disease. Chest. 2007;131:446-452.
These authors recruited 209 smokers who were admitted to the Creighton University coronary care unit with acute coronary syndrome or decompensated heart failure. Their mean age was about 55, and about two-thirds were men. Most had not graduated from high school, and all had significant cardiac disease, including coronary artery disease, acute myocardial infarction, and hypertension, and heart failure. Half were randomized to intensive intervention and half to usual care; there were more white people, more heavy smokers, and a trend toward more women in the intensive intervention group. All patients received about 30 minutes of smoking cessation advice prior to discharge, as well as the American Cancer Society self-help materials; this counseling was standardized and delivered by a single individual. Those patients who were randomized to intensive intervention also received standard counseling. In addition, they were asked to meet with a trained tobacco cessation counselor in a one-hour group counseling session once a week for 3 months after discharge. Topics covered in these sessions included relaxation training, contingency contracting, social support, coping skills training, stimulus control, and nicotine fading, as well as information about diet and exercise.
On average, participants in this group attended 8 sessions in the 3 months after hospital discharge. In addition, those in the intensive therapy group were offered free pharmacotherapy. About 75% of these subjects received such adjuvant therapy, including buproprion in 7%, nicotine replacement in 28%, and a combination of these therapies in 40%; it turns out that 17% of the usual care group also received pharmacotherapy with a similar distribution of agents. All subjects (intensive intervention and usual care alike) were seen at 3, 6, 12, and 24 months after enrollment. Those subjects in the intensive intervention group who were still smoking at 12 months (n = 58) were offered repeat intervention, and 28 elected to do so. Biochemically verified smoking cessation rates for those in the usual care group were 15%, 13%, 11 % and 9 % at 3 months, 6 months, 12 months and 24 months, respectively, which is quite dismal. Abstinence rates in the intensive intervention group at the same times points were 69%, 55%, 39%, and 33% (p < 0.0001 for all time points), which is also pretty discouraging. Over the two year follow-up period, 25 (23%) of those in the intensive treatment group were rehospitalized, compared with 41 (41%) in the usual care group (p = 0.01); most hospitalizations were due to cardiovascular causes. During follow-up, 12 (12%) and 3 (2.8%) of those in the usual care and intensive intervention group died, respectively (p = 0.026). After adjustment for ethnic background, age, gender, and admitting diagnosis, only age and treatment group assignment (usual care vs intensive intervention) affected mortality and hospitalization rates; since the ages of the participants in each group were essentially the same, only randomization to which kind of treatment group for smoking affected mortality.
Commentary
This is the first study to demonstrate that a smoking cessation program in high risk smokers reduces hospitalizations or mortality, and for this reason alone, it is noteworthy. This study also fairly conclusively demonstrates the worthlessness of "usual care," for smoking cessation, which is, of course, what smokers are generally getting (and providers are required to document) under current pay for performance guidelines. That should come as a surprise to no one, since it's well-established that short-term interventions don't accomplish much; 3 months is a minimal duration of treatment needed in order to demonstrate changes in smoking rates.1-16
It would be easy to get discouraged about the fact that only one-third of those in the intensive (and expensive) intervention group were confirmed to be abstinent from nicotine at 2 years. However, this is significantly greater than the 9% in the usual care group. More importantly, however, is the fact that those in the intensive intervention group were more likely to be alive!
So, what's the physician to do with the hospitalized smoker? Obviously, give "smoking cessation" advice, because that's what you're paid to do. Sadly, however, this is likely to be a waste of your time. It appears that our patients would be better off if we developed behavioral programs of at least 3 months in duration and were liberal with the pharmacotherapy. Most of us do not have behaviorists at our disposal, and (sadly) neither insurance nor patients are eager to pay for behavioral interventions. The two best-known and accessible behavioral smoking cessation programs are offered by the American Lung Association (ALA) and the American Cancer Society (ACS). The ALA's Freedom from Smoking Program17 is a 7 module, 6 week program. The ACS's Fresh Start Program18 is a 2 week program. Either of these could be a useful adjuvant to your personalized, sincere advice to quit smoking now, followed up by an offer to prescribe pharmacotherapy (which is increasingly covered by insurance). Be sure to tell your patients that quitting smoking NOW reduces their mortality rate AND the likelihood that they will be rehospitalized in the next 2 years.
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17. http://www.lungusa.org/site.
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In a group of smokers who were hospitalized with cardiac symptoms, a combination of 12 weeks of behavior modification counseling plus pharmacotherapy resulted in higher tobacco abstinence rates, lower re-hospitalization rates, and markedly reduced mortality rates compared with usual care over two years of follow-up.Subscribe Now for Access
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